Knowledge of medication abortion among adolescent medicine providers

Medication abortion for adolescents in the United States: Strengthening the role of pediatric primary care providers

BACKGROUND

Recent legal changes have led to mounting abortion restrictions in the United States (US), disproportionately impacting adolescents, who already face multifaceted barriers to abortion care. Informed by the framework of reproductive justice, adolescents who become pregnant deserve comprehensive, unbiased, and non-judgmental pregnancy options counseling, inclusive of all choices for pregnancy continuation and termination. Pediatric primary care providers are at the front lines of caring for adolescent patients' reproductive health needs and frequently diagnose pregnancy, provide pregnancy options counseling, and assist patients in accessing abortion care. They are uniquely poised to provide this care given their trusted, ongoing relationships with adolescent patients and their families, and their values of deep respect for adolescents' individuality and autonomy.

METHODS

In this commentary, we aim to describe the medical and legal landscape of adolescent abortion access in the US and provide recommendations to support pediatric primary care providers' involvement in abortion care. We focus on medication abortion, as the provision of medication abortion has the potential to encompass a broad group of clinicians, including pediatric primary care providers.

RESULTS

We discuss the importance of providing options counseling to adolescents within the reproductive justice framework, improving abortion education for pediatric providers, and expanding access to abortion care by supporting providers at an institutional level if they opt to provide medication abortions.

CONCLUSION

In light of the current legal landscape, the role of pediatric primary care providers in ensuring adolescent access to abortion care is ever more critical. Although many pediatric and adolescent providers already provide this important care, we, a team of obstetricians/gynecologists and adolescent medicine physicians, echo prior calls for improved training and institutional support for pediatric providers to counsel about and provide abortion-related care. We hope that highlighting the role of pediatric providers in this sphere will help center the needs of adolescent patients and help them fulfill their family planning goals.

Physician beliefs about abortion safety and their participation in abortion care

OBJECTIVE

To document physicians' beliefs about abortion safety and the associations between these beliefs and physician support for, referral for, and participation in abortion care.

METHODS

In a 2019 survey at the University of Wisconsin School of Medicine and Public Health, we assessed physicians' abortion attitudes, beliefs, and practices (N = 893). We conducted bivariate analyses followed by logistic regression to document relationships between physician beliefs about abortion safety and their support for, referral to, and participation in abortion care.

RESULTS

Four-in-five physicians (78%, n = 690) believed that abortion is very or extremely safe. Medical specialty (Obstetrics-Gynecology vs. other; adjusted odds ratio [aOR] = 10.58, 95% CI: 1.41-79.56), educational exposure to abortion (aOR = 1.43, 95% CI: 1.02-2.01), and religiosity (aOR = 0.59, 95% CI: 0.41-0.85) were associated with physicians' beliefs about the safety of abortion. Providers who believed that abortion was very/extremely safe were more likely to support medication (aOR = 2.99, 95% CI: 1.93-4.65) and procedural abortion (aOR = 3.56, 95% CI: 2.31-5.50) and refer patients for abortion care (aOR = 3.14, 95% CI: 1.90-5.01).

CONCLUSION

Although abortions are associated with extremely few adverse events, a sizable portion of surveyed physicians had incorrect perceptions of the safety of abortion. These beliefs were associated with decreased support and referrals for abortion care. Educational exposure to abortion is associated with more accurate assessments of abortion safety, underscoring the importance of training in this area. Considering the current abortion policy landscape, it is imperative for physicians to hold accurate knowledge about abortion so they can provide comprehensive counseling and, when indicated, referrals for safe and legal care.

Structural barriers or patient preference? A mixed methods appraisal of medical abortion use in England and Wales

Although patient choice of abortion method is a key component of quality care, medical abortion (MA) has become the most common method (87%) in England and Wales, as in many countries worldwide. This research aimed to critically examine factors influencing the growth in MA use in England and Wales. Mixed methods were used, combining multi-level regression analysis of national abortion statistics (2011-2020) and key informant interviews with abortion service managers, commissioners, and providers (n=27). Overall trends have been driven by growth in MA use for abortions under 10 weeks in the private non-profit sector. Variation in MA use between patient sub-groups and regions has narrowed over time. Qualitative findings highlight health system constraints that have influenced the shift towards MA, including workforce constraints, infrastructure requirements, provider policies, cost, and commissioning practices involving under-funding and competition, which have caused the private non-profit sector to limit method choice across their services to remain financially viable. While removal of legal restrictions on MA has expanded choice, similar policy progress has not been seen for surgical methods. The study concludes that abortion method choice has been constrained by structural health system factors, with potential negative consequences for service acceptability, inequalities, and patient-centredness.

Mifepristone for miscarriage treatment in Utah: A survey of clinician knowledge and assessment of an educational video on future use

Objectives

We aimed to: (a) describe current use of mifepristone for early pregnancy loss (EPL) management in Utah, (b) identify predictors of knowledge pre- and posteducational video, and (c) explore postvideo impacts on the likelihood to use mifepristone. Mifepristone is subject to the Food and Drug Administration's (FDA) Risk Evaluation and Mitigation Strategy (REMS) requirements.

Methods

Between September 2020 and March 2021 we surveyed Utah clinicians from six specialties caring for people experiencing EPL, recruited through professional organizations and hospital listservs. Participants viewed a 3.5-minute educational video on mifepristone for EPL and completed pre- and postvideo questionnaires. We evaluated predictors of high prevideo and improved postvideo knowledge using random forest regression conditional importance measures and partial dependency plots. We described current mifepristone use and video effects on likelihood to use mifepristone.

Results

Of 506 participants, most specialize in emergency medicine (172, 34%) and practice in private settings (253, 51%). Two-thirds had heard of mifepristone (328/471, 70%). Of 176/471 (37%) attempting provision of mifepristone, actual provision occurred for 59% (104/176). Baseline knowledge scores were low (mean 4.81/13 [37%] correct). Predictors of high prevideo knowledge include provision or attempted provision of mifepristone, having heard of mifepristone, providing EPL management expectantly or via medication, and specialty type. Mean postvideo knowledge scores improved by 3.27 points (68% improvement, paired t-test; 95% confidence interval 2.82-3.72, p < 0.0001). Postvideo, 66% (242/364) stated they are much more or somewhat more likely to use mifepristone, with compliance with FDA requirements cited as a barrier to utilization.

Conclusions

Among Utah providers, baseline mifepristone knowledge and use for EPL management are low. An educational video improved knowledge and likelihood of use, but FDA REMS requirements continue to be a barrier to including mifepristone in medication management of EPL.

Abortion Knowledge Among Advanced Practice Clinicians in Colorado

INTRODUCTION

Our objective was to quantify abortion law and care knowledge among Colorado advanced practice clinicians.

METHODS

We conducted a stratified random survey of advanced practice clinicians, oversampling women's health and rural clinicians. We assessed sample characteristics, positions on abortion legality, and knowledge of abortion law and care. Mean knowledge scores were compared by sample characteristics. Survey responses were compared by provision of pregnancy options counseling and positions on abortion legality. Linear regression models were used to examine knowledge scores.

RESULTS

A total of 513 participants completed the survey; the response rate was 21%. Abortion law knowledge questions (mean score, 1.7/7.0) ranged from 12% (physician-only law) to 45% (parental consent law) correct. For five of seven questions, "I don't know" was the most frequently chosen response. Abortion care knowledge questions (mean score, 2.8/8.0) ranged from 19% (abortion prevalence) to 60% (no elevated risk of breast cancer) correct. For four of eight questions, "I don't know" was the most frequently chosen response. Practicing in all other areas (e.g., family practice) was associated with lower abortion law and care knowledge than practicing in women's health. Providing options counseling was positively associated with abortion knowledge (law, β = 0.44; 95% confidence interval [CI], 0.10-0.78; care, β = 0.52; 95% CI, 0.08-0.95). Compared with participants who believe abortion should be legal in all circumstances, those who believe abortion should be illegal in all circumstances had similar abortion law knowledge (β = -0.03; 95% CI, -0.65 to 0.59), but lower abortion care knowledge (β = -1.85; 95% CI, -2.34 to -1.36).

CONCLUSIONS

Abortion knowledge is low among Colorado advanced practice clinicians and education is needed.

Access experiences and attitudes toward abortion among youth experiencing homelessness in the United States: A systematic review

Objectives

We sought to review the literature on the access experiences and attitudes toward abortion among youth experiencing homelessness in the United States.

Methods

We conducted a systematic review of peer‐reviewed literature published from 2001 to 2019. We included qualitative studies involving US participants that focused on access experiences, views, or accounts of unintended pregnancy and/or abortion among youth experiencing homelessness. We excluded studies published before 2001 as that was the year mifepristone medication abortion was made available in the US and we aimed to investigate experiences of access to both medical and surgical abortion options.

Results

Our thematic analysis of the data resulted in five key themes that characterize the abortion attitudes and access experiences of youth experiencing homelessness: (1) engaging in survival sex and forced sex, (2) balancing relationships and autonomy, (3) availability does not equal access, (4) attempting self-induced abortions using harmful methods, and (5) feeling resilient despite traumatic unplanned pregnancy experiences.

Conclusions

Youth experiencing homelessness experience barriers to abortion access across the US, including in states with a supportive policy context and publicly funded abortion services. In the absence of accessible services, youth may consider harmful methods of self-induced abortion. Improved services should be designed to offer low-barrier abortion care with the qualities that youth identified as important to them, including privacy and autonomy.

Termination of pregnancy: Staff knowledge and training

OBJECTIVES

In January 2019, Termination of Pregnancy (TOP) services were introduced in Ireland allowing the termination of pregnancies < 12 weeks. This study aimed to investigate staff knowledge and training on early TOP and views regarding challenges to successful integration of the service within a large maternity hospital.

STUDY DESIGN

A questionnaire, modelled on interim clinical guidance and previous studies on the topic, was distributed to clinical staff in a large maternity hospital in 2019. Descriptive analysis and a hierarchical multiple regression were performed using SPSS.

MAIN OUTCOME MEASURES

Levels of knowledge on TOP among staff, training received and main challenges to the service.

RESULTS

Of the total of participants (n = 133), just one-quarter correctly answered all questions on the current legislation and 63.2% on complications. Male gender, education level (diploma/certificate), and age (<30 years) negatively contributed to overall knowledge. 'Medical' job position positively contributed to knowledge levels. Most respondents (88%) had not received training prior to introduction of TOP services. Of those who did, few (9%) believed it to be sufficient. The main identified challenges to the service were lack of training and education, staffing and resources.

CONCLUSIONS

Low levels of knowledge among staff suggests that training is required to ensure the provision of a safe and effective TOP service. Our findings indicate that updated and clearer clinical guidance on TOP services is also needed.

Women's voices and medical abortions: A review of the literature

Globally, a growing proportion of induced abortions are medical abortions. The procedure has been hailed as a revolutionary technology, which, according to experts, has the potential to transform women's experiences of abortion and the way abortion services are accessed. Noticeably absent in the discourse, however, are women's voices. More specifically, there is a lack of understanding about what shapes women's preferences for medical abortion and the challenges they experience in accessing the drugs for the procedure. We conducted a systematic review of the literature to draw attention to these important issues which exist, but are often embedded within research highlighting other dominating aspects of medical abortions. A comprehensive search of four databases - supplemented by searching reference sections of selected articles, tracking their citations, and hand searching special editions on medical abortion - was conducted. A total of 45 peer-reviewed studies met our inclusion criteria. The studies were assessed for quality and analyzed using a critical interpretive synthesis approach. The findings revealed significant variations in women's preferences for surgical versus medical abortions. Country-specific abortion laws, implementing protocols, side-effects, rates of failures, and the need to verify the abortion shaped women's preference for abortion methods. Overall, women who preferred medical abortions did so because they perceived it as a 'natural' and safe procedure that can be self-conducted at home, thereby reducing their dependency on the health system. However, women face significant barriers to medical abortion care. These include legal requirements around type of provider, site of service, need for follow-up, providers' limited knowledge of the procedure, and preferences for surgical abortions. Borderless internet-based services have enabled some women to circumvent these barriers. Our review suggests that medical abortions are used by women either in countries where the health system is fully supportive or where the health system is completely disengaged, usually due to restricted abortion laws. In those countries where abortions are legal but often difficult to access due to health system barriers, women tend to prefer surgical abortions.

Abortion Knowledge and Attitudes Among Psychologists and Graduate Students

Abortion is often misunderstood and steeped in misinformation. Laypeople and medical professionals tend to have limited abortion knowledge. Among the public, individuals who hold accurate information about abortion are more likely to endorse pro-choice attitudes than individuals who are misinformed. We explored knowledge of, and attitudes toward, abortion among 142 psychologists and graduate students. Participants responded accurately, on average, to 68% of the items on a true–false measure of abortion knowledge. In addition, participants with higher levels of accurate knowledge were more likely to endorse pro-choice attitudes. Participants were especially likely to incorrectly answer items related to the prevalence, availability, and current legality of abortion in the United States. Analyzing qualitative interviews with a subset of 13 participants, we generated four themes related to knowledge and attitudes about abortion: Assuming Proficiency Despite Minimal Training, Pursuing Outside Knowledge and Training, Framing Abortion Around Identities, and Perceiving and Experiencing Consequences from Abortion Attitudes. Implications for training are delineated.

Quantity over quality-Findings from a systematic review and environmental scan of patient decision aids on early abortion methods

Background

The availability and effectiveness of decision aids (DAs) on early abortion methods remain unknown, despite their potential for supporting women's decision making.

Objective

To describe the availability, impact and quality of DAs on surgical and medical early abortion methods for women seeking induced abortion.

Search strategy

For the systematic review, we searched MEDLINE, Cochrane Library, CINAHL, EMBASE and PsycINFO. For the environmental scan, we searched Google and App Stores and consulted key informants.

Inclusion criteria

For the systematic review, we included studies evaluating an early abortion method DA (any format and language) vs a comparison group on women's decision making. DAs must have met the Stacey et al (2014). Cochrane review definition of DAs. For the environmental scan, we included English DAs developed for the US context.

Data extraction and synthesis

We extracted study and DA characteristics, assessed study quality using the Effective Practice and Organization of Care risk of bias tool and assessed DA quality using International Patient Decision Aid Standards (IPDAS).

Results

The systematic review identified one study, which found that the DA group had higher knowledge and felt more informed. The evaluated DA met few IPDAS criteria. In contrast, the environmental scan identified 49 DAs created by non‐specialists. On average, these met 28% of IPDAS criteria for Content, 22% for Development and 0% for Effectiveness.

Conclusions

Research evaluating DAs on early abortion methods is lacking, and although many tools are accessible, they demonstrate suboptimal quality. Efforts to revise existing or develop new DAs, support patients to identify high‐quality DAs and facilitate non‐specialist developers' adoption of best practices for DA development are needed.

Medical versus surgical methods of early abortion: protocol for a systematic review and environmental scan of patient decision aids

INTRODUCTION

Currently, we lack understanding of the content, quality and impact of patient decision aids to support decision-making between medical and surgical methods of early abortion. We plan to undertake a systematic review of peer-reviewed literature to identify, appraise and describe the impact of early abortion method decision aids evaluated quantitatively (Part I), and an environmental scan to identify and appraise other early abortion method decision aids developed in the US (Part II).

METHODS AND ANALYSIS

For the systematic review, we will search PubMed, Cochrane Library, CINAHL, EMBASE and PsycINFO databases for articles describing experimental and observational studies evaluating the impact of an early abortion method decision aid on women's decision-making processes and outcomes. For the environmental scan, we will identify decision aids by supplementing the systematic review search with Internet-based searches and key informant consultation. The primary reviewer will assess all studies and decision aids for eligibility, and a second reviewer will also assess a subset of these. Both reviewers will independently assess risk of bias in the studies and abstract data using a piloted form. Finally, both reviewers will assess decision aid quality using the International Patient Decision Aid Standards criteria, ease of readability using Flesch/Flesch-Kincaid tests, and informational content using directed content analysis.

ETHICS AND DISSEMINATION

As this study does not involve human subjects, ethical approval will not be sought. We aim to disseminate the findings in a scientific journal, via academic and/or professional conferences and among the broader community to contribute knowledge about current early abortion method decision-making support.

TRIAL REGISTRATION NUMBER

This protocol is registered in the International Prospective Register of Systematic Reviews (CRD42015016717).

Factors associated with provision of long-acting reversible contraception among adolescent health care providers

PURPOSE

To identify provider and practice characteristics associated with long-acting reversible contraception (LARC, either progesterone contraceptive implants or intrauterine devices [IUDs]) provision among adolescent health care providers.

METHODS

We used data from a previously conducted survey of US providers on reproductive health to predict provision of any form of LARC as well as progesterone contraceptive implants or IUDs specifically using Chi-square and multivariate logistic regressions.

RESULTS

One third of providers reported any LARC provision. In logistic regressions, residency training in obstetrics/gynecology or family medicine (rather than internal medicine/pediatrics) was the strongest predictor of LARC provision, particularly for IUDs.

CONCLUSIONS

A minority of providers reported offering IUDs or contraceptive implants, most of whom had received procedural women's health training. Increasing the number of providers offering this type of contraception may help to prevent adolescent pregnancies and may be most easily accomplished via training in contraceptive implant provision.